American Association of Colleges of Nursing. 2013 - All Rights Reserved. Evidence-Based Practice Karen N. Drenkard, PhD, RN, NEA-BC, FAAN Executive Director American Nurses Credentialing Center This program generously funded by the Robert Wood Johnson Foundation
Evidence-Based Practice: Practice based on the best available evidence that also incorporates: -patient values and preferences - clinician judgement and expertise (Sherwood and Barnsteiner) Using evidence to guide nursing practice
Key Terms Research conduct is the systematic investigation of clinical phenomenon or the generating of new knowledge. Research Utilization (RU) was a term used in the 1980 s and 90 s to describe a two-step process of dissemination and implementation. Dissemination is the systematic efforts to make research available Implementatron is the systematic implementation of scientifically sound, research-based innovation.
Translational Research Translational research is the testing of the effect of interventions aimed at promoting the rate and extent of adoption of EBP by healthcare providers.
Link to Safety and Quality Safe, effective delivery of patient care requires the use of nursing practices consistent with the best available knowledge.
Learner Objectives By the end of this module, the learner will be able to: 1. Define Evidence-Based Practice - the content. 2. Define the requirements for graduate level competencies 3. Describe the barriers to implementation of Evidence Based Practice 4. Describe teaching strategies for graduate level when teaching evidence based practice
Evidence-Based Practice the content
Steps in EBP 1. Develop a researchable question 2. Search for best evidence available and assess the strength of that evidence 3. Complete a critical analysis and synthesis of the evidence 4. Develop recommendations for practice 5. Evaluate the outcome of evidence based practice changes. Numerous models have been published to guide nurses in moving to EBP. Commonly used nursing models include the Iowa, STAR, Hopkins and University of Arizona models.
1. Develop a researchable question The PICO model is often used to define a problem and formulate a specific question: Population Intervention Comparison Outcome
Develop a researchable question An example of the PICO is as follows: In hospitalized patients over 60 years of age, how effective is a falls-prevention program in comparison to the normal standard of care in decreasing falls and falls injury rates by 50%? The question guides the search for evidence so the more explicit the question, the easier it is to develop the search strategies.
Teaching Strategy #1 Sacred Cows Contest: 1. What is the most traditional nursing practice done in this clinical area? 2. What is the least logical nursing practice happening in your area? 3. What is the most time consuming practice in your area?
2. Search for the best evidence available Searching for evidence difficult and complex. Numerous templates for conducting systematic reviews. Information is gathered from several sources including: systematic reviews, clinical practice guidelines, and searching journal publications for pertinent research articles.
Sources of Synthesized Knowledge Sources of synthesized knowledge include: National Guidelines Clearing House Sigma Theta Tau International Evidence-Based Nursing Worldviews on Evidence-Based Nursing The Johanna Briggs Institute Cochrane Collaborative Health Information Resources
EB Summaries of Systematic Reviews Evidence summaries or systematic reviews provide a foundation for EBP activities. Clinicians often do not have the time to summarize the total evidence for a question. Systematic reviews may be published and indexed in large databases such as Medline and CINAHL.
Clinical Practice Guidelines EB clinical practice guidelines are systematically developed statements that help clinicians and patients make decisions about health care for specific clinical circumstances. They often are developed by a multidisciplinary group, followed by external review prior to publication. The National Guidelines Clearinghouse has guidelines developed in the US as well as internationally.
3. Complete a critical analysis and synthesis of the evidence Assess the strength of the evidence: Systematic and metaanalysis reviews Randomized control trials Cohort studies Case Control studies Level of Evidence Review Case Reports Expert opinion
4. Develop recommendations for practice A comprehensive and detailed plan including communication of the change to all those affected, training requirements, development of detailed protocols, and notifying other departments and individuals who may be affected by the change is included in the dissemination plan. Active interventions such as self-study, learning labs, reminders, and decision supports are more likely to induce change than passive education.
Patient Values and Clinical Expertise Join in the Equation Little has been written regarding patient/family preferences and values related to EBP as well as the role of clinical expertise. Generally EBP has focused on the translation of research into practice. However, research evidence alone is not sufficient to ensure sound clinical decisions necessary for effective health care.
Incorporating Patient / Family Preferences Question prompts for patients, and coaching to develop skills in questioning clinicians and deliberating about options improve patient/family member decision-making abilities. Kleinman s questions for ascertaining patients beliefs and values may serve as a useful reference. Patient-centered care may at times conflict with evidencedriven care and that patient preferences have priority over evidence-based recommendations.
Clinical Expertise Clinical decision making complex process Requires more than research to guide practice. Proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Experienced clinicians use both individual clinical expertise and the best available external evidence.
5. Evaluate the outcome of evidence based practice changes Determine how the practice change is used. Audit and feedback demonstrates the gap between actual and desired results and address questions such as did the clinicians receive the information about a practice change and did they adhere to the practice change. How difficult or smooth was it to use the new way?
Barriers to EBP
Assess the Barriers to Using the Knowledge Consideration of barriers that may be encountered and resolving them prior to dissemination will help to ensure the success of the EBP. This includes identifying and obtaining resources that may be necessary.
Barriers to EBP Barriers identified include: Lack of time to locate and synthesize knowledge Negative attitudes towards research and EBP Lack of skill to search the literature and to interpret evidence Access to the internet and computerized resources The perception of lack of authority to change practice These barriers need to be kept in mind even as one moves through the steps in the process.
Teaching Strategy #2 Improving Evidence Based Practice in Systems: Assess a system to identify barriers to implementing evidence based practice Design an evidence based structure Choose strategies to improve use of evidence based practice and develop a plan
Graduate Level Competencies
Graduate Level Competencies Knowledge Understand the content methods and processes Determine the evidence gaps Address the gaps Evaluation of organizational structures and cultures that promote EBP Skills Differentiate between research, EBP, and QI Role model clinical decision making Promote a research agenda Lead and marshal resources for EBP Design organizational systems that support EBP Attitudes Value the process Champion the changes Value the scientific process
Graduate Level Teaching Strategies
Teaching Tips Enthusiasm is contagious. Approach the content in a positive and upbeat way. Role model the use of evidence based practice. Share examples from your own practice during lectures and small group report out. Millenial students want pedagogy of engagement Don t lecture at them engage them in the work. Whenever possible, the work should be interactive. Have the class work in small groups as much as possible. Consider experiential approaches. This will require a practice partner / clinical service partnership.
Teaching Tips Cite examples of clinical research in class. Allow the students whenever possible to choose their clinical interest area to conduct evidence analysis. Teach them how to critique a nursing research study using any of the research guides available. Invite a guest speaker to share a case study of an experience where research was incorporated into clinical practice. Have the students review the 5 steps in the EBP process did the case study touch on all of the steps? Develop researchable questions in a fun way consider a contest, or a game show format for generating ideas for questions that they want answered or want to know more about. American Association of Colleges of Nursing. 2013- All Rights Reserved.
Teaching Strategy #3 Development and Implementation of a Practice Change Based on Evidence Develop practice recommendations based on the EBP process steps Prepare an environment for change Implement a practice change